PWGSC-TPSGC 2012 - Interpretation Of Medical Examination For Pension Purposes

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Interpretation Of Medical Examination For Pension Purposes

Provision of the information requested on this document is required under paragraphs 13(1)(b) and (d) and section 28 of the Public Service Superannuation Act (PSSA) and sections 42.1, 43.2 and 43.3 of the PSSA Regulations. The information will be used for the purpose of determining entitlement to a pension for medical reason. The personal information is described in Personal Information Banks PWGSC PCE 702 and HCan PCE 701/703, and will only be used and disclosed in accordance with the provisions of the Privacy Act. Under this act, the individual to whom the information pertains has the right to request access to and correction of the personal information, if erroneous or incomplete. The records will be retained by the department for two years following the last administrative action, and then destroyed.

This form must be completed electronically. If not possible, please use dark ink and capital letters.

Plan Member's Personal Information

Preferred Language
Preferred Language

Carefully read instructions before completing.

A. General Information (to be completed by the plan member)

Type of application (check the applicable box)

B. Declaration of Plan Member

I understand that this application is initiated for medical retirement.

A copy of my work description is attached.

C. Examining Physician

C. Examining Physician Instructions

The details of the medical examination should be entered on form HC/SC 3312E. Forms PWGSC-TPSGC 2012 and HC/SC 3312E should then be sent to the appropriate Medical Services Branch office, located at:


Please do not send form HC/SC 3312E or confidential medical information to any non-medical government office.


I, the undersigned, duly qualified medical practitioner, certify that I have made a detailed examination of the above-named plan member and that in my opinion the said individual:

(Check one box only)

(months and years)

D. Health Canada

Note To Medical Services Branch:

The original of form PWGSC-TPSGC 2012 should be forwarded to the Public Service Pension Centre - Mail Facility, 150 Dion Blvd, PO Box 8000, Matane QC G4W 4T6. Complete number 1 or 2 below.

A copy of the completed form should be sent to the employer indicated in Section A.


Where disability commenced on or after January 1, 1996 (refer to definition 1 on the INSTRUCTIONS page)


Where disability commenced before January 1, 1996 (refer to definition 2 on the INSTRUCTIONS page)

(months and years)

For Office Use Only


  1. The plan member must complete Sections A and B.
  2. The plan member may seek assistance from his compensation advisor or the designated person in his organization to complete Section A and obtain a copy of his work description (Duties and Requirements of Position) which must be attached and sent with the form.
  3. On page 1, the plan member must provide either his PRI or his Pension Number. The pension administration only requires one of the two to identify the account.
  4. Only indicate the Termination Date, if it is known.
  5. This form, along with the Occupational Health Assessment Report (HC-SC 3312) must be sent to the Medical Services Branch office indicated in Section C.
    Please contact the Public Service Pension Centre to obtain the HC-SC 3312E form.


  1. A plan member is disabled if he is suffering from a physical or mental impairment that:
    1. prevents him from engaging in any employment for which he is reasonably suited by virtue of his education, training or experience; and
    2. can reasonably be expected to last for the remainder of his lifetime.
  2. A plan member is disabled if incapable of pursuing regularly any substantially gainful occupation.
  3. In considering what constitutes "substantially gainful occupation", the impairment must prevent the plan member from engaging in employment commensurate with his education, training and experience.

PWGSC-TPSGC 2012 (12/2009)